Home-Based and Hospital-Based Stroke Rehabilitation - Case Study Example

Running Head: STROKE REHABILITATION SETTINGS Home Based and Hospital Based Stroke Rehabilitation Name: Grade Course: Tutor’s Name: 11th, October, 2009 Introduction Stroke rehabilitation programs are meant to help patients who have survived stroke and have lost normal body function due to brain damage. The brain controls all functions of the body and its damage affects the activities of various body parts that it controls. If for example a patient suffers stroke and movement of limbs is impaired, regaining movement requires rehabilitation. The kind of services offered in each rehabilitation program is however dependent on the patient, the severity of the condition and the availability of stroke rehabilitation resources. Post stroke rehabilitation has two different settings. It can be hospital based or home based. Home based stroke rehabilitation can also be classified into two; that is continued rehabilitation at home with stroke rehabilitation specialists visiting and monitoring the patient at home and making use of community stroke rehabilitation resources. Hospital based is also in two different forms, that is in patient rehabilitation and out patient rehabilitation. Rehabilitation begins after a patient is found to be stable enough to participate in the rehabilitation. Admission to any rehabilitation program requires assessment which will determine if a patient should be admitted or not. A second assessment is also done after initial rehabilitation to find out if the patient is stable enough to continue with the rehabilitation at home or in the hospital. There are advantages and disadvantages associated with these settings and this paper aims to describe the two different stroke rehabilitation program settings, giving their benefits and disadvantages, then giving a recommendation on which is best for the patient. REHAB A (Hospital) Rehab A Guidelines Ric’s Rehabilitation centre is a unit meant for stroke rehabilitation and caters for neurological patients. It receives patients from Ric’s Hospital and from any other hospitals provided they meet the admission criteria. The first guideline in this rehabilitation is working according to the clinical guidelines for acute stroke management which ensures the services provided are up to standard, the facilities are efficient and caters for all stroke patients’ requirements and the unit has all the required specialists. Based on the available facilities and the rehabilitation specialists, this unit only accepts a total number of 35 patients. This is for effective management and provision of quality services. This unit has specific criteria for selecting patients to be admitted. The patients must have neurological disorders, they must have good control of their bowels and bladders, they must have required cognition levels and sitting balance and they must not be using internal or external catheters. The inpatients are taken care of by the multidisciplinary team which have to ensure that they receive standard care. The team has to meet every week to review the progress of each patient, their accomplishments and set new goals. Assessment Tools/Outcome Measures Used in Rehab A Effective treatment of patients needs assessment to find out if the set goals are being accomplished. The goals work towards good health of the patient. In this rehabilitation unit, there are several assessment tools used to determine the patients’ progress the tools are as follows: National Institute of Health (NIH) Stroke Scale which is used to measure stroke severity Chedoke-McMaster Stroke Assessment (CMSA), which is used to measure the upper extremity function of the patient Chedoke-McMaster Stroke Assessment –used to measure the lower extremity Line Bisection meant for assessing the patient’s visual perception (HSFO, 2007) The Diagnostic Aphasia Assessment, used to screen a patient for language impairment in order to be admitted for rehabilitation (HSFO, 2007) Nine Hole Peg Test measures the arm function 6-Minute Walk Test measures the lower extremity function Berg Balance Scale (BBS) measures the patient’s balance, Patient Satisfaction survey and Amsterdam-Nijmegan Everyday Language Test (ANELT) which assesses the functional communication of the patient Other outcome assessment tools are the FIMTM (Functional Independence Measure) meant for assessing the daily living Self-Care Activities and the Reintegration to Normal Living Index that measures the Instrumental Activities of Daily Living (HSFO, 2007). 1st Patient’s Case Daniel is a 37 year old engineer who suffered a cardio embolic stroke due to aortic valve replacement surgery. He developed a hemi paresis and a mild visual neglect. Before being affected by the stroke, Daniel was working at a construction, very physically active and played regularly in the adult hockey program. After the stroke, he could not do any of those as his limbs were affected as well as his vision. He was also the coach of his son’s hockey team. Daniel wanted to recover and go back to all the previous things he used to do. He was put under hospital based rehabilitation until he recovered (Dobkin, 2003). He did well in his acute rehabilitation but was retained in the hospital to complete his rehabilitation program. He was not admitted in the hospital but was enrolled for outpatient stroke rehabilitation. The initial follow up indicated that Daniel could coach his son’s hockey team and was also back at the hockey rink. The next follow up indicated his improved functionality with his ability to skate with his son. After several months, Daniel was able to play competitive hockey. General Rehabilitation Goals Any stroke rehabilitation program aims at improving the general functioning of an individual. They help the patient relearn the skills lost during brain damage (NINOS, 2009). Disabilities caused by stroke are such as sensory disturbances, movement paralysis, emotional disturbance and speech impairment (NINOS, 2009). The rehabilitation programs therefore aim at helping the affected people regain functionality in the areas affected. The aim of stroke rehabilitation programs is to assist those individuals with disabilities to achieve improved psychological and physical performance (Duncan & Stason, 2004). It is to promote functional independence. Considering Daniel’s case, the general goals would be to get Daniel to walk independently without support, to get Daniel to regain his hockey playing skills, to regain his coaching skills, to regain his physical activity nature, skating skills and to regain his normal sight (Adams et al, 2006). Specific Rehabilitation A Goals Depending on the patient’s case, the specific goals would be to ensure the patient regains his normal functions as before through services offered by various rehabilitation specialists. The specific rehabilitation goals are set by members of multidisciplinary team, either individually or in conjunction with the other team members. Daniel’s physical functioning needs to be improved as well as his visual perception. The physician’s goals would be to control spasticity in his affected limbs and to improve his mobility. The nursing Rehabilitation goals of the rehab include; ensuring there are no contractures, ensuring patients get there medication at the right time, encourage the patients to use the affected limbs, providing safe environment in the unit and to ensure effective communication with other rehabilitation members about the patient’s progress (NINOS, 2009). The physical therapist will aim at helping Daniel achieve utmost motor control strength, mobility and balance and to reduce spasticity in the affected limbs (White & Truax, 2007). This means helping Daniel regain the use of the affected limbs. The physician recommends the rehabilitation program appropriate for Daniel as well as caring for health which includes preventing occurrence of another stroke. The specific goal is therefore to ensure Daniel’s long term care (Alexander et al, 2000). The neurologist has the role of taking care of the patient during the acute rehabilitation in the hospital. The goal is therefore to ensure the patient receives the necessary rehabilitation services by coordinating the acute-care stroke teams (Adams et al, 2006). The occupational therapist would work towards making the patient regain independence in his daily activities, to improve the patient’s perception and cognition, to improve mobility and to ensure the environment the patient is being rehabilitated supports his goals, has the necessary facilities and is safe. Daniel would be attended to by social workers, whose goals would be to provide counselling services and education to the patient and the family members, to provide the necessary transitional care and to ensure Daniel gets access to community rehabilitation programmes after discharge (Dobkin, 2003). Rehabilitation Program for this Patient Daniel was under stretching, balance and strengthening exercises; his limbs were treated using Botulinum toxin injection for spasticity improvement and he was put under 24 nursing care both at home and when at the hospital. He was attended to by the social worker who saw to his needs as escribed above and also underwent occupational therapy (Duncan & Stason, 2004). Rehab B (Home Based) Rehab B Guidelines The home based rehabilitation is for continued treatment of stroke patients discharged from hospital. The patients are to receive therapy two times in a week and only receive such therapy more than twice when the patient’s condition requires so. The needs of the patients determine the kind of services or therapy to be offered. The multidisciplinary team therefore set the goals. Nursing care is not provided unless required for example in cases when the patient has wounds and requires wound care or when the patient requires medication (Stein et al, 2009). The equipments to be used in this kind of setting are determined by the rehabilitation team. The patients can be attended to under loan but this only extends to 4 months. Their progress is monitored after every week and the multidisciplinary team meets to review their cases and set new goals. This program takes 4 weeks and can only accommodate 32 patients per term (Stein et al, 2009). Assessment Tools /Outcome Measures used in Rehab B The goals of a rehabilitation program are to ensure the patient is treated and cared for considering the type of disease or disability. These goals therefore determine the kind of assessment tools used to find out the outcomes of the work already done by the stroke care teams. Home based stroke rehabilitation has the following assessment tools: De Morton mobility Index (DEMMI), a Carer strain Index, Lawton’s activities of daily Living assessment, patient satisfaction survey, AROC ambulatory data collection form, a Functional Independence Measure scale (FIM) and a carer satisfaction survey (White, 2007). 2nd Patient Case Jane is a 37 year old lady living with her family in one big house. Jane had a stroke on August 5th 2008 and became completely paralysed on the rights side. She also lost all her power of speech. 4 days later, a CT scan was done and this showed loss of function on the left hemisphere of her brain. She however regained her speech after ten days showing the potential of quick recovery under her condition. Jane could not still walk and could not use the right arm to hold objects or even move. She managed to make her first steps on 5th September. Her arms could move two weeks later (Alexander et al, 2000). After another month, Jane could move alone using a tripod. Her improved condition happened partly in the hospital and most of it at home. She was discharged on the 30th of October and continued with her rehabilitation at home. Late February 2009, Jane had almost completely recovered with the ability to walk to the local shops, to use her right arm and talk normally (Alexander et al, 2000). Patient’s Status at the Time of Discharge: According to the description of Jane’s case given above, the patient was in a stable condition. She had started regaining her speech and body mobility. She needed to regain complete functioning of the affected body parts which could be done in a different stroke rehabilitation setting apart from in patient. She underwent speech therapy sessions at the hospital and even at home. Attention was given to sensory deficits and speech difficulties before she was sent home (Alexander et al, 2000). General Rehabilitation Goals The main activities of Jane are not specific but under normal circumstances, a patient would want to go back to normal life. The general goals of the rehabilitation would be to make Jane make Jane get her normal life back, that is be able to perform all that she use to do before the stroke attack for example shopping (White, 2007). Specific Rehabilitation Goals Specific rehabilitation goals depend on the patient’s condition which dictates the type of specialists and services the patient should be offered. A speech pathologist for example has the duty to ensure that the patient gets his or her normal speech functioning. With this kind of role, the pathologist has to examine the patient and set goals depending on the patient’s status and response. In the above case for example, the specific rehabilitation goals are set by the physical therapist, the neurologist, and the neuro-psychologist. They will aim at making Jane regain her normal functionality and live independently, aim at improving the strength of her limbs, improve her balance, help her regain her speech, to structurally manage the home environment and to ensure the patient gets domestic help. The speech pathologist goals are to improve clarity of her speech, improve her comprehension and expression and to improve her swallowing (White, 2007). Rehabilitation Program for this Patient The patient was offered with daily physiotherapy sessions that aimed at improving her strength and balance. This was done by a physiotherapist and his assistant who also aimed at improving her mobility. Jane was also given a regular speech therapy which was done twice a week to perfect her speech condition. Home assistance was arranged by the rehabilitation unit and this was done by the rehabilitating social worker. It is important for Jane to have knowledge about her condition as well as her family members; this was made possible by the rehabilitation’s social worker. The nurse ensured she received her medications in time. Comparison between Rehab B and Rehab A Rehabilitation Programmes Advantages of REHAB B over Rehab A According to Stein and the other colleagues, the patients function better in a familiar environment which is home and in hospitals. It gives the patients the benefit of practicing skills in their own living environment as well as developing compensatory strategies (2009). Home based rehabilitation provides an easier way of rehabilitation for patients who lack transport to outpatient rehabilitation program sessions. Patients are also allowed to follow individual schedules unlike outpatient rehabilitation where the patient has to attend sessions that have to consider by other patients. When undergoing rehabilitation at home, the patients have the advantage of choosing to attend less demanding therapy sessions or to attend more intensive therapy sessions. This suits most patients with only one therapist or those who lack transportation to patient rehabilitation centres. Home based rehabilitation reduces the expenses that should have been used in hospital based setting hence reducing the burden of cost to the family members. This shows that hospital based rehabilitation is cost effective (Anderson et al, 2000). Disadvantages of Rehab B Hospital based rehabilitation period depends on the recovery of the patient while home based has a specific period (4 weeks). This does not consider the patients recovery (Dobkin, 2003). This kind of rehabilitation increases burden on care givers, it reduces availability of physician monitoring or professional support, has limited availability of resources necessary for treatment in a rehabilitation program and lack of support from fellow patients (Adams et al, 2006). Another disadvantage is that they do not have specialized equipment unlike inpatient cases (Dobkin, 2003). The rehabilitation specialists have to travel to reach the patients while inpatients are easily reachable (Anderson et al, 2000). Rehabilitation at home has no 24 hour supervision like the hospital based which gives 24 hours medical cover (Adams, 2006). Conclusion It is important for a stroke patient to be discharged after treatment of acute stroke. Discharge however does not mean the end of treatment. The patients have to undergo rehabilitation to ensure complete recovery and good health. Both outpatient and home based rehabilitation programs provide such rehabilitation and the choice of a setting depends on the patient requirements, condition or the family member’s preferences. The choice also depends on the family’s financial ability. From the above discussion, it is evident that home based and hospital based rehabilitation programs are not different considering the guidelines and the goals except for the specific goals. This means that choice of a setting can be made by assessing the advantages, the disadvantages and finances. Based on the following describe advantages and disadvantages, a family with little resources will consider home based rehabilitation. A family or a patient who wishes to regain normal functions in a familiar environment may also chose home based rehabilitation. The guidelines also dictate if a patient should go for home based rehabilitation or not. With no home support, the patient is forced to go for out patient rehabilitation. The patient’s condition also determines if or not he or she goes for home rehabilitation. The two cases described above are similar and both their conditions supported home based rehabilitation since they did not need a lot of stroke specialists except for the physician, physical therapist and speech and language pathologist for Jane and physician and physical therapist for Daniel. It would have been economical for Daniel to opt for home rehabilitation. Reference List Adams, H. P., Del Zoppo, G. J. and Von Kummer, R. (2006). Management of Stroke: A Practical Guide for the Prevention, Evaluation, and Treatment of Acute Stroke. 3rd Ed. New York, US: Professional Communications. Alexander, M. F., Fawcett, J. N. and Runciman, F. J. (2000). Nursing Practice: Hospital and Home : the Adult. 2nd Ed. England, UK: Elsevier Health Sciences. Anderson, C., Rubenach, S., Mhurchu, C.N., Clark, M., Spencer, C.& Adrian Winsor, A. (2000).Home or Hospital for Stroke Rehabilitation? Results of a Randomized Controlled Trial I: Health Outcomes at 6 Months, Stroke, 31, 1024-1031. Black-Schaffer, R. M. (2005). Program Focus. Retrieved on 8th Oct, 2009 from: http://www.spauldingrehab.org/ourprograms/strokedetails. Dobkin, B. H. (2003). The Clinical Science of Neurologic Rehabilitation, 2nd Ed. London, UK: Oxford University Press. Duncan, P. W. and Stason, W. B. (2004). Post-Stroke Rehabilitation: Clinical Practice Guideline. Massachusetts, US: DIANE Publishing. Heart and Stroke Foundation of Ontario. (2007). Consensus Panel on the Stroke Rehabilitation “Time is Function”. Retrieved on 8th Oct, 2009 from: http://www.swostroke.ca/content/files/8.%20%20Appendix%20M%20Stroke%20Rehabilitation%20Outcome%20Measures.pdf Law, M. C. (2002). Evidence-Based Rehabilitation: a Guide to Practice. SLACK Boston, Massachusetts: Incorporated. National Clinical Guidelines for Stroke. .(2004). 2nd Ed. Intercollegiate Stroke Working Party. National Institute of Neurological Orders and Stroke (NINOS). (2009). Post-Stroke Rehabilitation Fact Sheet. Retrieved on 7th Oct, 2009 from: http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm Stein, J., Harvey, R. L. and Macko, R. F. (2009). Stroke Recovery and Rehabilitation. Sydney, Australia: Demos Medical Publishing. White, B S. And Truax, D. (2007). The Nurse Practitioner in Long-Term Care: Guidelines for Clinical Practice. New York, US: Jones & Bartlett Publishers. Read More